Abstract

This volume is based upon a review of available literature and intervention experiences selected from modern and traditional societies. It is augmented by the lessons learned through the editors' experience in teaching courses on health communication and foundation of health behavior in graduate public health programs at several leading universities in the United States and abroad over two decades. Examples and implications are also drawn from extensive involvement in diverse health and health communication projects, such as the on-going community-based public health project in South Central Los Angeles sponsored by UCLA and the Kellogg Foundation. This particular project is designed to develop health promotion communication interventions.

Part III: Evaluation of Health Communication in Multicultural Populations

Copyright

All rights reserved. No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher.

Preface

[Page ix]

The primary aim of this volume is to critically review issues and approaches to health communication, with special reference to public health interventions in multicultural communities. As a scientific and professional specialty, multicultural communication is in its infancy. The theories and models presented in communication textbooks and mainstream literature and often used for intervention planning are almost always based upon research done with the dominant white population and from the perspective of evaluating media effects on a target population (see Chapter 1 for examples). These theories and models are valuable conceptual tools for designing interventions in populations similar to those used for original research that served as their basis. But these theories and models are generally color-blind and gender-blind; they do not inform us about the key issues, factors, and forces intrinsic to cultures and genders that affect effective health communication in multicultural community. In this volume, we focus on key issues, factors, forces, and challenges in health communication from a multicultural perspective. We define multicultural community as a community where people from distinctly different cultures live, come into contact, and interact with one another to form a new way of life, both dynamic and different from each of its parts or cultures.

We have entered the third millennium with unprecedented scientific and technological innovations that have profoundly changed our societies and lives [Page x]beyond our expectations. Science and technology have enabled us to eradicate or control epidemics, which killed millions and disabled many more. They have enabled us to travel in space, unravel the secrets of atoms, map every human gene, clone living beings, and amass wealth at an unprecedented level. Innovations in industrial development, medicine, and public health have prolonged human life and have significantly reduced mortality and morbidity rates due to major infectious diseases and epidemics. Consequently, world population has been growing at increasing rates. People are living longer, and women are living longer than men, especially in the older age groups.

At the same time, multiculturalism has emerged as a major challenge in social planning, both globally and nationally. But our understanding of the dynamics of multicultural communities as they affect planned social change remains at a very rudimentary level. Rapid globalization (including increased international travel, trade, education, migration, and entertainment) and the communication revolution have transformed our social realities fundamentally. At the international level, rapid globalization and the communication revolution have blurred national and cultural boundaries. We can instantly observe and participate in events across the globe, share our experiences with people around the world, and live like members of a vast and complex global village. This globalization of information exchange, travel, education, communication, commerce, and entertainment has produced dual effects. First, the younger generation is becoming more similar across cultures. The emerging global youth culture includes rock music and blue jeans, shared preferences in movies, TV programs, videos, and Internet activites, and other commonalities in lifestyle and even in political and personal aspirations. Second, an increasing cultural gap between the younger and older generations is leading to greater inter-generation and inter-gender tensions and conflicts within families and communities. Rapid industrialization and globalization have also significantly increased the gaps between the “haves” and the “have-nots” in terms of access to the benefits of these progress, including access to communication hardware and content.

On the domestic front, many urban areas are rapidly becoming demographically multicultural. For instance, in 1990, the 15 largest metropolitan areas in the United States became truly multicultural; that is, there was no single ethnic majority. The United States Census Bureau projects that by the year 2050, whites will be reduced to 52% of our national population. By another decade, whites will be one of several minorities. Our communities have also become more complex and multicultural. Increasingly, people in our communities live, work, eat, play, and form personal and family ties with people from cultures [Page xi]that are distant geographically (originating from tens of thousands of miles across the globe) and fundamentally dissimilar (e.g., in language, religion, identity, and tradition). This new multicultural reality means that in planning social policy and interventions, we can no longer assume a homogenous population. Theories and methods that were effective in monocultural settings or in communities with one dominant culture may not be as effective for social change in multicultural communities. We need to understand the realities of multicultural communities and build our social policies and prevention intervention on that understanding.

Effective health communication is more than disseminating health messages using popular media or enhancing people's compliance with medical regimens. It involves initiating and sustaining fundamental changes at individual and societal levels. At the individual level, it requires changing personal lifestyle and risk behaviors that are deeply rooted in culturally conditioned beliefs, attitudes, practices, norms, and patterns of personal relations (e.g., behavior related to food and nutrition, sex and reproduction, health care utilization, and personal safety). At the societal level, it requires changing cultural values, social norms, customs and practices, social organizations, and intercultural relations (including communication systems) that directly affect health-related behavior and status. Finally, multicultural communities consist of minorities and high-risk groups who are most likely to be poor, underserved, and powerless. Poverty, prejudice, and exclusion from social policy and governance that adversely affect their health and quality of life are major barriers to effective health promotion interventions in multicultural communities. Lack of multicultural competency among policy planners and professionals further aggravates the problem. Effective disease prevention and health promotion interventions for and in such communities must extend beyond communication of health information and education and deal with issues of community empowerment and participation. Athough in recent years there has been a growing recognition of the importance of multicultural health communication, there is a paucity of research-based literature and exemplary case studies that can provide adequate guidance to professionals who are involved with health promotion in multicultural communities. In this volume, we present our critical analysis of multicultural health communication issues and exemplary case studies as a contribution to our collective understanding.

There are many persons, too many to name individually, who have directly or indirectly contributed to this volume. First: Years of communication and interactions with our numerous colleagues and graduate students have significantly helped us in clarifying the issues we have presented in this volume. Second: [Page xii]Countless national and international health-related organizations have provided us with invaluable opportunities, as consultants and collaborators, to work and gain firsthand experience in health communication in distant and disparate cultures. They also are too numerous to mention. Third: we must acknowledge our indebtedness to the editorial team at Sage Publications. Acquiring Editor Margaret H. Seawell made a critical contribution by her efforts that led to Sage's decision to publish the volume. Heidi Van Middlesworth assisted in making sure all tables, figures, and other major elements were complete and ready to use. Linda Gray has meticulously edited the manuscript for clarity, consistency, and completeness of the text; her editorial help has been invaluable. Diana E. Axelsen played a major role by expediting the production of this volume. Finally, words cannot express the depth of support received from and sacrifice made by our family members as we worked on this volume.

Introduction

[Page xiii]

When races come together, as in the present age, it should not be merely the gathering of a crowd; there must be a bond of relation, or they will collide with each other.

—Rabindranath Tagore (1925/1966, p. 216)

Many Indians and Turks speak the same tongue; Yet many pairs of Turks find they're foreigners. The tongue of mutual understanding is quite special: To be one of heart is better than to have a common tongue.

—Rumi (1994, p. 37)

Effective multicultural communication is much more than the use of a common language or media. The primary objective of this volume is to examine the role of health communication within the context of health promotion and disease prevention (HPDP), which make up the new public health paradigm for achieving the health objectives of our nation.

[Page xiv]A major paradigm shift in the health care ideology and system is in process both globally and nationally. At the global level, the Alma-Ata Declaration of 1978, endorsed by over 160 nations, formally recognized that a new primary health care (PHC) paradigm should replace current emphasis and dependence on expensive tertiary clinical care in both rich and poor nations (WHO/UNICEF, 1978). The PHC strategy focuses on primary prevention through “active community participation”; health information education and communication (IEC) is a key strategy for promoting and sustaining community participation. According to the PHC paradigm, communities must be active partners in the planning and implementation of health care policies and services, not passive beneficiaries of health services planned and provided by professionals.

Within the United States, a consensus currently exists among scholars, planners, and professionals that our continued emphasis on sophisticated and expensive tertiary care will not improve the overall quality of health of Americans. This new consensus and paradigm is described in detail in the landmark document titled Healthy People 2000: National Health Promotion and Disease Prevention Objectives (U.S. Department of Health and Human Services [DHHS], 1991). This HPDP paradigm identifies 22 areas of national priority and emphasizes effective applications of the public health model for achieving health objectives for the nation. In contrast to the medical paradigm, the distinctive features of the public health paradigm are that (a) its goal is prevention of disease and promotion of positive health rather than treatment of the sick, (b) its unit of intervention is the public (community) not individual patients, and (c) its strategy is to facilitate lifestyle and societal changes necessary for reduction of risks and promotion of health for communities as a whole. The public health model focuses on promoting and sustaining desired changes through effective partnerships between health planners, providers, and the public. Within this new paradigm of HPDP, health communication emerges as a vital component with vastly expanded roles extending far beyond the traditional emphasis on communication and education for patient compliance or for timely use of health services.

The HPDP paradigm requires effective use of communication interventions for achieving additional objectives, including empowerment of communities at risk, advocacy on behalf of the underserved groups for affecting policy and services, and coalition and consensus building for social actions for better health. According to the Ottawa Charter, which helped revolutionize health promotion globally, “Health promotion is the process of enabling people to increase control over, and to improve, their health.… Health promotion goes beyond [Page xv]health care. … At the heart of this process is the empowerment of communities, their ownership and control of their own endeavours and destinies (“Ottawa Charter” 1996, pp. 329, 330, 331). This includes the education and reeducation of millions of health professionals of our nation to prepare them to be more responsive to the needs of the communities as defined by them (the new public health paradigm and its implications for multicultural communities are discussed in Chapter 2 of this volume). This is admittedly a formidable challenge, but the challenge of developing effective health promotion and communication strategies is far greater in multicultural and disadvantaged communities for reasons explained in the following section.

Our population also is increasingly becoming multicultural. The first U.S. census in 1790 recorded 81% of the population as white; in 1900, the population of whites had actually grown to 88% (U.S. Department of Commerce and Labor, 1909). In contrast, the 1990 census showed a decline in the non-Hispanic white population to 75% (U.S. Department of Commerce, 1998a); according to the latest projection, by 2050 the non-Hispanic white population will be reduced to 53% (U.S. Department of Commerce, 1998b). In another decade, non-Hispanic whites will be one of many minorities of our nation.

Until recently, the United States based its social policy on the “melting-pot” paradigm. This assimilationist view held that all ethnic minorities should and do desire to blend into the mainstream dominant culture; therefore, social policies should be based on the reality of one population, and the emphasis should be on designing the most effective standard intervention paradigm that would best serve most people's needs. It has become clear, especially during the last two decades, that a multicultural reality has replaced the melting-pot metaphor. One prominent sociologist and a strong proponent of the assimilationist position summed up the current situation best in his recent book We Are All Multiculturalists Now (Glazer, 1997). This aptly titled new demographic reality predicates that, to be effective, health promotion and communication interventions must be responsive to the needs and dynamics of multicultural communities.

Over 70 years ago, the philosopher-poet Rabindranath Tagore (1925/1966) cautioned Indian political and educational leaders with these words: “When races come together, as in the present age, it should not be merely the gathering of a crowd; there must be a bond of relation, or they will collide with each other” (p. 216). The last Los Angeles riot proved how prophetic he was. Rodney King summarized our national frustration in five words: “Can't we all get along?” The central premise of this volume is that effective health promotion communication in multicultural and underserved communities must go [Page xvi]beyond dissemination of health information and promotion of an agenda set by outside experts using a common language—that in order to be effective, it must first establish “a bond of relation” with people from dissimilar cultures and then channel this force to build bridges between peoples' priorities, aspirations, and resources.

Multicultural, multiethnic communities consist of culturally diverse groups that vary significantly from one another in terms of their (a) objective needs and subjective priorities, (b) interethnic stereotypes and relations affecting social participation (c) culturally rooted beliefs and values affecting health-related practices, (d) language and communication behavior, (e) social networks, and (f) leadership structures. Cultures may also vary significantly from one another in terms of the values and beliefs they hold about birth, death, illness, and major life events; meanings, causes, and consequences of these events; and appropriate preventive and healing practices. Finally, multicultural and disadvantaged urban communities consist of high-risk groups with special needs. Effective health communication strategy in such communities must be based on a sound understanding of the way a culture affects health and related behavior as well as an understanding of the special needs of various groups.

In recognition of the needs of special populations, the landmark report that defined our national strategy for HPDP states: “Special population groups often need targeted preventive efforts, and such efforts require understanding the needs and the disparities experienced by these groups. General solutions cannot always be used to solve specific problems” (U.S. DHHS, 1991, p. 29). There is no standard model of effective health communication, and even if there were one, it is not likely to be effective among all ethnic groups. Typically, social science theories and methods that guide communication policy and strategies are based on research conducted primarily among the dominant segment of the white population; it would be unwise to assume that what is true for a majority would be equally valid for other groups. The social reality is more complex in communities where there is no single dominant majority (e.g., South Central Los Angeles; the UCLA School of Public Health, which has five academic departments, each with its own ideology and priorities). In such diverse communities, an effective health promotion communication will require a “bottom-up” planning process in partnership with the diverse segments of the community and the organizations serving them. This new disease HPDP paradigm requires a new philosophy of prevention, new communication strategies, and new leadership responsive to the needs of multicultural communities.

[Page xvii]Available literature on communication theory and practice in general and on health communication is impressive and is rapidly expanding, but the literature is very weak in dealing with communication and health promotion issues of multiethnic and disadvantaged communities. As Huston et al. (1992) write, “We know a great deal about the functions of television for children, a modest amount about those for the elderly and women, and relatively little about those for many ethnic minorities” (p. 132). Although one can identify excellent text and reference books on communication in general and mass media campaigns in particular (see below under “Scope of This Volume”), our recent on-line search failed to identify a single book with its primary focus on community-based HPDP communication in multicultural communities. The authors of this volume have been teaching required graduate courses on health behavior and health communication at several leading schools of public health in the nation over two decades; throughout this period, they were unable to find a suitable text or reference book that focuses on health communication from a multicultural context. This book addresses this serious gap in the literature. It presents an analysis of key issues and factors affecting health promotion interventions in general and the role of health communication within the context of the new paradigm of HPDP in multiethnic communities in particular. The book examines communication processes and their influence on health-related behavior from a “cultural diversity” or a “multicultural” perspective rather than from the commonly used “technocentric” (or “media effects”) perspective. The technocentric perspective uses a “media effects on the dominant majority (MEDM)” paradigm; it selects a popular media technology (e.g., TV, printed media, interactive network) and examines its effects on a specific behavior or group (e.g., violence, substance abuse among adults, children).

The cultural diversity perspective—hereafter, multicultural perspective—begins with the premise that ethnic groups have unique and culturally conditioned beliefs, values, knowledge, attitudes, practices (BVKAP), and ethnic communication patterns that affect their health-related behavior. Effective health communication must be based on the positive “cultural capitals” of various groups, and it requires an emphasis on local solutions rather than solutions through national media. Reports of various commissions and study groups on the effects of TV violence and pornography in mass media on aggression and antisocial behavior are examples of a “technocentric” approach looking at the effects of media on target behavior. This approach may be valid when one deals with a culturally homogeneous population in which the impacts of cultural diversity on health behavior and media use may not be a critical issue. But in a culturally diverse community, the differences among ethnic [Page xviii]groups in their culturally anchored values, beliefs, and preferred communication behavior may have independent effects on health communication and health behavior of the members of various groups. The “cultural relativity” approach begins with the salient cultural attributes or givens of distinct ethnic groups and examines how these givens interact with modern communication media and the existing health care system in affecting health-related decisions and action within and between groups.

Scope of This Volume

This book does not attempt to review the entire field of health communication theories and research. For that purpose, there are excellent reviews of health communication from the MEDM perspective. These include Atkin and Wallack (1990); Backer, Rogers, and Sopory (1992); Bennet and Caiman (1999); DeFleur and Ball-Rokeach (1995); Harris (1995); Huston et al. (1992); Kreps and Kunimoto (1994); Oskamp (1989); Rice and Atkin (1989); Rogers (1973); Tulloch and Lupton (1997); and Wallack, Dorfman, Jernigan, and Themba (1993). Our volume does not intend to duplicate these valuable works. Instead, we focus on a multicultural health communication perspective and process, emphasizing our HPDP objectives for the nation and consequently on community-based primary prevention—that is, community-based actions to prevent people from illness and injury in the first place. Our aim is to identify forces and factors in multicultural communities as they affect health communication.

Organization of the Text

The text is organized into three parts. Part I deals with major trends affecting public health and theoretical, conceptual, and empirical literature germane to health communication in multicultural communities (Chapters 1–5). The second part includes in-depth analyses of seven case studies on health communication interventions in high-risk populations (Chapters 6–12). Part III deals with the lessons learned and issues raised in evaluation of health communication in multicultural communities (Chapters 13–14).

Chapter 1 deals with the changing dynamics of the health needs of populations and the emergence, over the last century, of the new public health paradigm [Page xix]Chapter 2 is on the global responses to the changing health needs in populations, including the evolution of the PHC paradigm globally and the emergence of the HPDP strategy for the nation. Chapter 3 looks at the changing roles of health promotion, public health organizations, and health communication in professional education and in health promotion interventions. Next, Chapter 4 discusses major theories and models of health behavior that guide health communication interventions and their implications in multicultural populations and the issue of “cultural competence.” The concluding chapter in Part I, Chapter 5, looks at the realities of working in a multicultural society, and at cultural similarities and differences among minority groups.

Part II deals with seven exemplary case studies dealing with health communication in different ethnic communities. Chapter 6 begins with a discussion of childhood injuries from a multicultural perspective. Chapter 7 reviews evaluation of the usefulness of the Health Diary in six Healthy Start sites. Chapter 8 looks at parent-child communication, particularly as it relates to the issue of substance abuse prevention. Continuing with child-based prevention strategies, Chapter 9 considers the effectiveness of peer education as it relates to STD/HIV prevention. Chapter 10 expands on this topic, looking at HIV prevention among homeless youth. Chapter 11 discusses a community-based health promotion program for American Indian and Samoan older women. The section ends with Chapter 12, which evaluates health communication campaign design, drawing lessons from a distribution campaign of the Wellness Guide in California.

In conclusion of the volume, Chapters 13 and 14 summarize the implications of our analysis in all chapters and of the case studies in this volume, findings derived from the authors original research, and health communication evaluation issues particular to multicultural communities.

Summary

The authors of this volume address three key questions: What are the realities of multicultural communities? What are the roles and limitations of mainstream communication media in these settings? What are the unique forces and factors that determine effective health communication in multicultural communities. To illustrate the current demographic shifts, the Los Angeles Times recently reported that “José” was the most popular name for newborn baby boys in Texas and California for 1998; for the first time, a Hispanic name [Page xx]replaced the usual John and Michael (“José Moves Into Top Spot,” 1999). This signifies two major social trends underscored in this book: (a) The proportion of minorities in the general population is growing faster than whites, and (b) society is becoming more multicultural as minorities choose not to melt into the mainstream by choosing English names—that is, increased pride in ethnic identity now overrides assimilationist hopes. Given these realities, we hope that our volume will at least raise important issues for active deliberation by researchers, policy planners, and the community alike. Through critical analyses of communication studies literature and primary experience from health communication case studies in multicultural communities, the authors of this volume illustrate what works and what does not, the problems encountered, and their implications for multicultural health communication.

U.S. Department of Commerce and Labor, Bureau of the Census. (1909). A century of population growth: From the first census of the United States to the twelfth, 1790–1900. Washington, DC: Government Printing Office.

About the Contributors

[Page 375]

Rina Alcalay, PhD, is Associate Professor of Communications and Rhetoric at the University of California at Davis and held a professorial position at the School of Public Health at UCLA for several years. She has had extensive experience in research, teaching, and consultations on issues of health communication with special reference to Hispanics and other underserved groups for over a decade. She is much sought after by national and international agencies for her established reputation as an expert in health communication in multicultural communities. She holds a doctorate degree in communication from Stanford University.

Shana Alex is Program Assistant at the UCLA Office of Public Health Practice. She is working on a master's degree in public policy at the University of California, Los Angeles, School of Public Policy and Social Research, focusing on health policy and the possibilities for reforming the health care system at the national level. Her other research interests include issues of multiculturalism and state and local regional issues facing California.

Robert A. Bell, PhD, is Professor of Communication at the University of California at Davis. He has expertise in communication theories and models for social and behavioral change. Among his recent projects are studies of social influence strategies for health promotion and investigations of the content and impact of [Page 376]direct-to-consumer drug advertising. He has worked with the Sacramento AIDS Foundation to develop strategies to overcome resistance to HIV testing among high-risk populations. He has been involved in evaluation research, including an evaluation of a social marketing intervention sponsored by The California Wellness Foundation and an evaluation of a physician-targeted medical education seminar on managed care. He is currently working in the role of co-principal investigator/analyst as part of an interdisciplinary team studying patients' requests, a project funded by the Robert Wood Johnson Foundation. His research has appeared in a variety of journals in public health, medicine, and communication. He earned his doctorate in communication from the University of Texas, Austin.

Gauri Bhattacharya, DSW, MSW, is a faculty member in the School of Social Work at the University of Illinois at Urbana-Champaign (UIUC). Her research interests and professional specialties include substance abuse prevention, the economics of substance abuse treatment, and access to health care services for HIV/AIDS. Current research projects focus on delineating the causal linkages of risk and protective factors to substance abuse (or no use) and examining the extent and the nature of the processes among adolescents in multicultural communities, and as the principal investigator on a number of projects funded by the National Institute on Drug Abuse (NIDA). She has developed community-based substance abuse prevention and intervention programs for adolescents. She has published on substance abuse prevention and health education on HIV prevention in peer-reviewed journals and authored several book chapters. She presents extensively at national scientific, public health, and medical meetings. She is a licensed and certified clinical social worker. Before joining in 1998, she was a principal investigator at the National Development and Research Institutes, New York. She received her DSW and MSW degrees from Adelphi University, Garden City, New York, and a master's degree in economics from Calcutta University, India.

Clifford Binder, MBA, coconducted the evaluation of the Health Diary for the Center for Health Policy Studies under contract with the Health Resources and Services Administration with James Wells. His research and evaluation activities include work for federal health care agencies, state health departments, and private health organizations. He is currently assessing Medicare contractor medical review activities and Medicaid network adequacy measures for the Health Care Financing Administration.

[Page 377]Linda Burhansstipanov, MSPH, DrPH, is Executive Director of Native American Cancer Initiatives, Inc., of Pine, Colorado. She is Western Cherokee (Tahlaquah, OK). She developed and implemented the Native American Cancer Research Program at the National Cancer Institute from 1989 to 1993. She was also the former director of the Native American Cancer Research Program of the AMC Cancer Research Center in Denver, Colorado. She was a full professor at California State University Long Beach and also taught part-time at UCLA. She has been the principal investigator of multiple Native American cancer research, service, and education grants.

Vicki J. Ebin, PhD, MSPH, is Assistant Professor at California State University, Northridge, in the Department of Health Sciences. Concurrently, she is the Project Director for the UCLA/CSULB Adolescent Tuberculosis Prevention Project. Her research interests include adolescent health, compliance issues, and community-campus partnerships. She received her degrees from the University of California, Los Angeles.

Deborah Glik, PhD, is Associate Professor at the UCLA School of Public Health and has also taught at the University of South Carolina. She is Co-Director of the UCLA Technical Assistance Group (TAG), which specializes in the assessment and evaluation of educational and community-based projects. Her expertise is in research on health behavior change, health communications, formative research, and program evaluation in community settings, having worked in both domestic and international settings. Substantive areas include evaluation and promotion of school and community immunization programs, infectious disease control, injury control, and evaluation of a broad range of programs and social interventions in schools and communities. She is currently conducting an evaluation of an immunization curriculum geared to sixth-grade students, a malaria curtains project in Malawi, and a child injury prevention project in South Central Los Angeles. Other recent evaluation projects include assessing the impact of Public Health Leadership training, WIC educational programs, and jobs training programs for inner-city and disadvantaged youth. Other current projects include development and evaluation of multimedia education in Latino communities, on topics such as immunizations, nutrition, and gestational diabetes, and research on the effectiveness of a teen theater program for U.S. adolescents sponsored by the Centers for Disease Control. She earned a doctorate in behavioral sciences and public health from Johns Hopkins University.

[Page 378]Fran Goldfarb, MA, CHES, is Director of Parent and Family Resources at the University of Southern California, Affiliated Program, Children's Hospital, Los Angeles. Her current research projects include Medical Home Project for Children with Special Needs and LA Connections: Improving Access to Primary and Preventive Care for Children With Special Needs. Previously, she was Director of the Community Action for Women's Health, Center for Healthy Aging (previously known as Senior Health and Peer Counseling). She did her graduate work in Family Life Education at Azusa Pacific College.

Snehendu B. Kar, MSc, DrPH, is Professor of Public Health at UCLA, where he's been since 1979. He is Director of the MPH Program for Health Professionals (MPHHP) in Health Promotion and Health Education and Codirector of Public Health Practice. His professional and research interests include acculturation and health, health communication in multicultural communities, empowerment and health education, and health promotion indicators. Previous positions include Associate Dean and Chair of the School and Department of Public Health (1984–1988), Head of the Behavioral Sciences and Health Education Division (1980–1984), and Chair of the Asian American Studies IDP (1980–1984) at UCLA; Associate Professor and Assistant Professor at the School of Public Health at the University of Michigan, Ann Arbor (1967–1978); and Deputy Assistant Director General (Research) at the Ministry of Health and Family Planning, Government of India, New Delhi. He received his MSc in psychology in 1958 from the University of Calcutta, India, and his master's and doctorate degrees in public health and behavioral sciences from the University of California at Berkeley.

Lené Levy-Storms, PhD, MPH, is Assistant Professor in the Department of Health Promotion and Gerontology and a Fellow of the Sealy Center on Aging at the University of Texas Medical Branch in Galveston, Texas. Her research interests include the social contexts of successful aging, long-term care use, and minority aging. Her current research focuses on how social networks influence self-care behaviors and the role of race, ethnic, and social factors on the use of formal care services among older adults. She holds a master's of public health in biostatistics and a doctorate in public health from the University of California, Los Angeles.

Angela Mickalide, PhD, CHES, is Program Director of the National SAFE KIDS Campaign, the only nationwide program for prevention of unintentional injuries among children ages 14 and under. She is an adjunct Associate Professor of [Page 379]Prevention and Community Health at the George Washington University School of Public Health and Health Services and an Associate in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins University School of Medicine. Prior to joining SAFE KIDS, she worked at the federal Office of Disease Prevention and Health Promotion, U.S. Public Health Service in Washington, D.C. Among her current public health leadership positions are as Governing Councilor for the American Public Health Association, Executive Board member of the International Society of Child and Adolescent Injury Prevention, and member of the Task Force on Injury Prevention for the American School Health Association. She earned a PhD degree in 1985 at Johns Hopkins University in Baltimore, Maryland, specializing in public health, psychology, and health education.

Donald E. Morisky, ScD, has worked at the UCLA School of Public Health since 1982, concurrently conducting research in Associate positions at the Johns Hopkins School of Hygiene and Public Health, the Charles R. Drew Post Graduate Medical School, and the UCLA Jonsson Comprehensive Cancer Center. From 1993–1994, he was chair of the Public Health Education Section of the American Public Health Association, and he has consulted extensively with the World Health Organization and other international health organizations. His current research focuses mainly on AIDS, particularly in the Filipina population. He received his doctorate degree from Johns Hopkins University in 1981 in behavioral sciences and health education.

Karen Thiel Raykovich, PhD, is a Senior Fellow in the Office of Planning, Evaluation and Legislation of the Health Resources and Services Administration where she directs the national evaluation of the Healthy Start Program. She has evaluated maternal, child, and adolescent health and social services programs at the federal, state, and local levels.

Lisa A. Russell, PhD, is Senior Research Associate with ETR Associates in Santa Cruz, California. Her research interests include health communication, health behavior, and mental health services. Specifically, she studies homelessness, child maltreatment, and mental health among youths and their families, and disaster communication, preparedness, and responses among adults. She received her PhD in public health from the University of California, Los Angeles.

Steven P. Wallace, PhD, is Associate Professor at the UCLA School of Public Health, Borun Scholar of the Anna and Harry Borun Center for Gerontological [Page 380]Research at UCLA, and associate director for community programs of the UCLA Center for Health Policy Research. His research focuses on the impact of race and ethnicity on the use of long-term care and the consequences of public policies for the health and quality of life of racial and ethnic minority elderly. He has published widely on his research in journals such as The Gerontologist, Journal of Gerontology: Social Sciences, American Journal of Public Health, and Journal of Aging Studies. His current research includes projects on (a) determining the consequences of managed care on access to health care by racial/ethnic minority elderly; (b) better understanding how culture, economics, and racism shape the use of long-term care; and (c) evaluating the implementation of health and welfare policy in California. He received his PhD in sociology from the University of California, San Francisco.

James A. Wells, PhD, is a health services researcher and epidemiologist. He co-conducted the evaluation of the Health Diary for the Center for Health Policy Studies under contract with the Health Resources and Services Administration with Clifford Binder. In addition to maternal and child health, his experience includes work in HIV/AIDS, substance abuse treatment, managed care, bioethics, scientific productivity, and health education. He is currently a research consultant with the Gallup Organization, working in the Government and Education Research Division. He received his PhD in sociology from Duke University and completed a postdoctoral fellowship in epidemiology at the Yale University School of Medicine.